This version of the State EMS Forms was posted on this site on 02/03/2006, and last revised by the state on 06/072007. Last updated 03/09/2010.

February 1, 2005, 20 EMS provider agencies in Connecticut began beta testing a separate, new, electronic data and reporting system, the EMS Data Collection System, that captures pre-hospital emergency response information. The EMS Data Collection System’s electronic reporting will replace the current paper based Quarterly Provider Activity reporting to OEMS that is required of all EMS provider agencies. The electronic system expands upon the type of essential emergency response information currently captured in the paper-based system, that includes the number, timing and types of emergency responses.

By December 1, 2005, OEMS and Digital Innovations (DI), the software vendor that developed CT’s EMS Data Collection System, will implement Phase 2 of the beta testing of the EMS Data Collection System at 30 hospitals, which will enable hospitals to receive the EMS response data captured and reported by the pre-hospital service provider. OEMS will provide computers and/or printers to any hospital unable to accept electronic data submissions from the service providers so the "run form" data can be entered, and printed out, for inclusion in the patient’s hospital record.

By April 1, 2006, OEMS and Digital Innovations will implement Phase 3 of the beta testing of the EMS Data Collection System at 30 hospitals, which will link the EMS Data Collection System with the hospital’s patient record and billing information system (s).

EMS Data e-PCR program has a transition date of January 1, 2009, all transport services and paramedic intercept service must move from paper Patient Care Reports to the e-PCR system. 

Per the Connecticut Traffic Records Strategic Plan for 2010

The use of NEMSIS was mandated beginning January 2007 and all EMS services provided Toughbook laptop computers were required to have Gold Standard NEMSIS compliant software and be trained in the use of this software. It should be noted, however, that the number of NEMSIS data elements captured in a Patient Care Report (PCR) depends upon the seriousness of the call for service. Beginning in June 2008, PCR data collected electronically was submitted to a server located in the Office of Emergency Medical Services. Emphasis in 2010 continues to assure that all PCR data that are collected electronically are Gold NEMSIS compliant. A memo was issued to all vendors and EMS providers requesting that 400+ NEMSIS required data elements be submitted as dictated by the specifics in each case, beginning in July 2009. To date DPH has received over 375,000 EMS Patient Care Reports from 175 EMS providers. The DPH plans to submit data to the NEMSIS project in 2010.

Click on the thumbnails below to view a full sized image.

Connecticut Patient Care Report

Select the following to view a printable Acrobat (.PDF) version. 

 First Responder Run Form(.PDF,125 k)

 BLS ALS Run Form Page 1(.PDF,125.92k)

 BLS ALS Run Form Page 2(.PDF,156.05k)   

 BLS ALS Run Form Page 3(.PDF,107.70k)

 Run Form Billing Section(.PDF,72.54k)

 Connecticut Injury Prevention and Control Plan, 2008 - 2012 (.PDF,2647.89k)

Click on the following links to view the corresponding files:

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